Lessons from accidental exposures are, therefore, an invaluable
resource for revealing vulnerable aspects of the practice of
radiotherapy, and for providing guidance for the prevention of
future occurrences. These lessons have successfully been applied to
avoid catastrophic events with conventional technologies and
techniques. Recommendations, for example, include the independent
verification of beam calibration and independent calculation of the
treatment times and monitor units for external beam radiotherapy,
and the monitoring of patients and their clothes immediately after
brachytherapy. New technologies are meant to bring substantial
improvement to radiation therapy. However, this is often achieved
with a considerable increase in complexity, which in turn brings
opportunities for new types of human error and problems with
equipment. Dissemination of information on these errors or mistakes
as soon as it becomes available is crucial in radiation therapy
with new technologies. In addition, information on circumstances
that almost resulted in serious consequences (near misses) is also
important, as the same type of events may occur elsewhere. Sharing
information about near-misses is thus a complementary important
aspect of prevention. Lessons from retrospective information are
provided in Sections 2 and 4 of this report.
General
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